Infertility affects about 7.3 million people in the U.S. This amounts to between about 12% to 15% of persons in the reproductive age population. (Source: National Survey of Family Growth, CDC 2002). Requirements for the initiation of pregnancy include ovulation and the production of a competent oocyte (egg), production of competent sperm, proximity of the sperm and oocyte in the reproductive tract, fertilization, transport of the embryo into the uterine cavity and implantation of the embryo into the endometrium. Many disease processes contribute to infertility in humans. The World Health Organization task force on Diagnosis and Treatment of Infertility determined in developed countries, diseases that contributed to infertility were attributed to the female partner in 37% of couples, to the male partner in 8% of couples, and to both partners in 35% of couples. Five percent of the couples had no identifiable cause of infertility (i.e., unexplained infertility). Diseases in females most often identified included: ovulatory disorder (25%), pelvic adhesions (12%), tubal occlusion (11%) other tubal abnormalities (11%), hyperprolactinemia (7%), endometriosis (15%) and no identifiable diseases (20%). Decision by persons in the reproductive population to defer childbearing due to careers and other lifestyle factors are increasing the numbers of infertile couples. Over the past three decades, women have been choosing and will continue to choose to pursue higher education and careers and thus postpone marriage. Professional couples tend to get married at an older age and are continuing to delay having children, well into their late thirties up to their mid forties, because of changing life styles and career demands. These trends increase the need for fertility treatments. Also, alternative life styles, i.e., same sex couples, offer a major challenge to options in fertility treatments, which are not currently well recognized or addressed. Technology is continuing to advance in efforts to resolve infertility issues. Egg cryopreservation is becoming an option for women who may have medical conditions that will require treatments that may cause sterility. Also, egg cryopreservation may be beneficial to women who are delaying reproduction. Currently technology is being developed to give a female the opportunity to freeze oocytes (eggs) during the best time of her reproductive years; thus, providing the ability for these women to have children at a later time in life. Freezing of oocytes provides an opportunity not just for women who choose to delay having children but also for women who are diagnosed with cancer or other illness and who may require the use of radiation and/or chemotherapy which may leave the these women sterile. Currently there are gaps in services available, in regard to egg cryopreservation. However freezing of oocytes alone will not solve all of the potential future problems for these women. Assisted reproductive techniques and/or treatments with in vitro fertilization will be required for fertilization of frozen oocytes and the transfer of embryos into the uterus of these women to achieve a pregnancy.
The need for providing coverage for infertility treatment is huge and steadily increasing. As of 2002, infertility affected at least 7.3 million women and their partners in the United States. This is about 12% of the reproductive age population in the U.S. (Source: National Survey of Family Growth, CDC 2002). Of those affected, one third of infertility is due to male factors, one third is due to female factors and the other third is a combination of problems in both partners.
The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome (PCOS), early menopause, benign uterine fibroids and pelvic adhesions.
Fallopian tube damage usually results from inflammation of the fallopian tube (salpingitis). Chlamydia, a sexually transmitted disease, is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever. Tubal damage is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.
Endometriosis occurs when the uterine tissue implants and grows outside of the uterus often affecting the function of the ovaries, uterus and fallopian tubes. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.
Some cases of female infertility are caused by ovulation disorders. Hormonal disruptions in the part of the brain that regulates ovulation can cause low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation. Specific causes of hypothalamic-pituitary disorders include injury, tumors, excessive exercise and starvation.
Elevated prolactin (hyperprolactinemia). The hormone prolactin stimulates breast milk production. High levels in women who aren't pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. In addition, some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing can be a sign of high prolactin.
Polycystic ovary syndrome (PCOS). In PCOS, the body produces too much androgen hormone, which affects ovulation. PCOS is associated with insulin resistance and obesity.
Early menopause (premature ovarian failure): Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35. Although the cause is often unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.
Benign uterine fibroids. Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by blocking the fallopian tubes.
Pelvic adhesions: Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. This scar tissue formation may impair fertility.
OTHER CAUSES: A number of other causes can lead to infertility in women:
Medications: Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
Thyroid problems: Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
Cancer and its treatment. Certain cancers particularly female reproductive cancers often severely impair female fertility. Both radiation and chemotherapy may affect a woman's ability to reproduce. Chemotherapy may impair reproductive function and fertility in men and women.
Other medical conditions: Medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, HIV/AIDS, kidney disease and diabetes, can affect a woman's fertility.
Caffeine intake. Excessive caffeine consumption reduces fertility in the female.
TABLE 1Female InfertilityAnovulation10 to 15%Pelvic factor30 to 40%Cervical factor10 to 15%
Percentage of women who are infertile, by age from three national U.S. surveys:
TABLE 2AgeUnder 3030-35 36-4041-45>45% with infertility after20%20%33%66%95%one year of tryingMiscarriage rate15%15%17%34%53%
CAUSES OF MALE INFERTILITY: A number of things can cause impaired sperm count or mobility, or impaired ability of the sperm to fertilize the egg. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, general health and lifestyle issues, and overexposure to certain environmental elements.
IMPAIRED PRODUCTION OR FUNCTION OF SPERM: Most cases of male infertility are due to problems with the sperm, such as:
Impaired shape and movement of sperm. Sperm must be properly shaped and able to move rapidly and accurately toward the egg for fertilization to occur. If the shape and structure (morphology) of the sperm are abnormal or the movement (motility) is impaired, sperm may not be able to reach or penetrate the egg.
Low sperm concentration. A normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of 10 million or fewer sperm per milliliter of semen indicates low sperm concentration (subfertility). A count of 40 million sperm or higher per milliliter of semen indicates increased fertility. Complete failure of the testicles to produce sperm is rare, affecting very few infertile men.
Varicocele: A varicocele is a varicose vein in the scrotum that may prevent normal cooling of the testicle, leading to reduced sperm count and motility.
Undescended testicle. Undescended testicle occurs when one or both testicles fail to descend from the abdomen into the scrotum during fetal development. Because the testicles are exposed to the higher internal body temperature, compared with the temperature in the scrotum, sperm production may be affected.
Testosterone deficiency (male hypogonadism). Infertility can result from disorders of the testicles themselves, or an abnormality affecting the hypothalamus or pituitary gland in the brain that produces the hormones that control the testicles.
Genetic defects. In the genetic defect Klinefelter's syndrome, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production and possibly low testosterone.
Infections. Infection may temporarily affect sperm motility. Repeated bouts of sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. If mumps, a viral infection usually affecting young children, occurs after puberty, inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.
In many instances, no cause for reduced sperm production is found. When sperm concentration is less than 5 million per milliliter of semen, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.
IMPAIRED DELIVERY OF SPERM: Problems with the delivery of sperm from the penis into the vagina can result in infertility. These may include:
Sexual issues. Often treatable, problems with sexual intercourse or technique may affect fertility. Difficulties with erection of the penis (erectile dysfunction), premature ejaculation, painful intercourse (dyspareunia), or psychological or relationship problems can contribute to infertility. Use of lubricants such as oils or petroleum jelly can be toxic to sperm and impair fertility.
Retrograde ejaculation. This occurs when semen enters the bladder during orgasm rather than emerging out through the penis. Various conditions can cause retrograde ejaculation including diabetes, bladder, prostate or urethral surgery, and the use of certain medications.
Blockage of epididymis or ejaculatory ducts. Some men are born with blockage of the part of the testicle that contains sperm (epididymis) or ejaculatory ducts. Some men lack the tube that carries sperm (vas deferens) from the testicle out to the opening in the penis.
No semen (ejaculate). The absence of ejaculate may occur in men with spinal cord injuries or diseases. This fluid carries the sperm from the penis into the vagina.
Misplaced urinary opening (hypospadias). A birth defect can cause the urinary (urethral) opening to be abnormally located on the underside of the penis. If not surgically corrected, this condition can prevent sperm from reaching the woman's cervix.
Anti-sperm antibodies. Antibodies that target sperm and weaken or disable them usually occur after surgical blockage of part of the vas deferens for male sterilization (vasectomy). Presence of these antibodies may complicate the reversal of a vasectomy.
Cystic fibrosis. Men with cystic fibrosis often have missing or obstructed vas deferens.
GENERAL HEALTH AND LIFESTYLE: A man's general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:
Emotional stress: Stress may interfere with certain hormones needed to produce sperm. The sperm count may be affected by excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress. Infertility can affect social relationships and sexual functioning.
Malnutrition: Deficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.
Obesity: Increased body mass may be associated with fertility problems in men.
Cancer and its treatment: Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility.
Alcohol and drugs: Alcohol or drug dependency can be associated with poor health and reduced fertility. The use of certain drugs also can contribute to infertility. Anabolic steroids, for example, which are taken to stimulate muscle strength and growth, can cause the testicles to shrink and sperm production to decrease.
Other medical conditions: A severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, Cushing's syndrome, or anemia may be associated with infertility.
Age. A gradual decline in fertility is common in men older than 35.
ENVIRONMENTAL EXPOSURE: Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm count either directly by affecting testicular function or indirectly by altering the male hormonal system. Specific causes include:
Pesticides and other chemicals: Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production and testicular cancer. Lead exposure may also cause infertility.
Overheating the testicles: Frequent use of saunas or hot tubs can elevate the core body temperature. This may impair sperm production and lower sperm count.
Substance abuse: Use of cocaine or marijuana may temporarily reduce the number and quality of sperm.
Tobacco smoking: Men who smoke may have a lower sperm count than those who don't smoke.
SOCIAL TRENDS AS CAUSES OF INFERTILITY: In addition, social trends of deferred childbearing have increased in the past three decades due to men and women pursuing higher education and careers and thus marriage has been postponed to a latter age. Professional couples tend to get married at an older age and are continuing to delay having children well into their late thirties to mid forties because of changing life styles and career demands. These drastically increase the need for infertility treatments due to advanced maternal age. Often times, these treatments call for the employment of cutting-edge techniques such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), preimplantation genetic diagnosis (PGD), embryo and sperm cryopreservation and storage as well as alternative treatments such as egg, sperm, and embryo donations and surrogate carriers for those who lost the ability to successfully carry the pregnancy. Also, alternative life styles (same sex couples) offer a major challenge to options in infertility treatments that are currently not well recognized or addressed.
TABLE 3Male InfertilityMale30 to 40%
TABLE 4Male and Female InfertilityUnexplained infertility10%
TABLE 5Population of the United StatesAgeYear 2000Year 20100-419,175,79821,426,1635-920,549,90520,705,84510-1420,528,07219,767,29115-1920,219,89021,336,475State Infertility Insurance Benefits and Laws
Currently there are only fourteen states that require insurers to either cover or offer to cover some form of infertility diagnosis and treatment. Those states are Arkansas, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia. Fertility insurance coverage in most if not all of these states is limited in scope and does not encompass the full range of options available for infertility treatments. In addition, the Employment Retirement Income and Security Act of 1974 exempts companies that self-insure from state regulation. These insurers are under heavy pressure to curtail and further reduce fertility coverage, treatments and benefits. These State mandated insurers are for the most part limited and deficient. Following is a description of the laws that govern how these states cover fertility insurance.
ARKANSAS: Arkansas law requires all health insurers that cover maternity benefits to cover the cost of IVF. Health maintenance organizations are exempt from the law. Patients need to meet the following conditions in order to get IVF coverage:
The patient must be the policyholder or the spouse of the policyholder and be covered by the policy;
The patient's eggs must be fertilized with her spouse's sperm;
The patient and her spouse must have at least a two-year history of unexplained infertility, OR the infertility must be associated with one or more of the following conditions:
Endometriosis: Fetal exposure to diethylstilbestrol, also known as DES;
Blocked or surgically removed fallopian tubes that are not a result of voluntary sterilization; or
Abnormal male factors contributing to the infertility. The patient has not been able to achieve a successful pregnancy through any other less costly infertility treatment for which coverage is available under the policy.
IVF procedure must be performed at a medical facility licensed or certified by the Arkansas Department of Health. Those facilities certified by the Department of Health must conform to the American College of Obstetricians and Gynecologists guidelines for in vitro fertilization clinics or meet the American Fertility Society's (sic) minimal standards for programs of in vitro fertilization.
The IVF benefits in Arkansas are subject to the same deductibles and co-insurance payments as maternity benefits. The law also permits insurers to limit coverage to a lifetime maximum of $15,000. (Arkansas Statutes Annotated, Sections 23-85-137 and 23-86-118).
CALIFORNIA: California law requires certain insurers to offer coverage for infertility diagnosis and treatment. That means group health insurers covering hospital, medical or surgical expenses must let employers know infertility coverage is available. However, the law does not require those insurers to provide the coverage; nor does it force employers to include it in their employee insurance plans.
California law defines infertility as: The presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility; or the inability to conceive a pregnancy or carry a pregnancy to a live birth after a year or more of sexual relations without contraception.
California law defines treatment as including, but not limited to:
Diagnosis and diagnostic tests;
Medication;
Surgery; and Gamete Intrafallopian Transfer, also known as GIFT.
California law specifically exempts insurers from having to offer IVF coverage. Also, the law does not require employers that are religious organizations to offer coverage for treatment that conflict with the organization's religious and ethical purposes. (California Health and Safety Code, Section 1374.55).
CONNECTICUT: Individual and group health insurance policies are required to cover medically necessary expenses for infertility diagnosis and treatment. Infertility is defined as the inability to conceive or sustain a successful pregnancy during a one-year period.
Covered treatments include ovulation induction, interuterine insemination, IVF, uterine embryo lavage, embryo transfer, GIFT, ZIFT, and low tubal embryo transfer. Coverage is limited to individuals who have maintained coverage under the policy for at least a year.
Some additional limitations apply: The covered individual must be under 40 years of age;
There is a life-time coverage maximum of four cycles of ovulation induction, three cycles of IUI, and two cycles of IVF, GIFT, ZIFT, or low tubal embryo transfer (with not more than two embryo transfers per cycle);
Covered treatments must be performed at facilities that conform to standards and guidelines developed by ASRM or SREI.
Individuals seeking coverage must disclose to their insurance carrier any prior infertility treatments for which they received coverage under a different insurance policy. Religious employers are permitted to exclude coverage for treatments that are contrary to their bona fide religious tenets. (Public Act No. 05-196).
HAWAII: Hawaii law requires certain insurance plans to provide a one-time only benefit for outpatient costs resulting from in vitro fertilization. Those plans include individual and group health insurance plans, hospital contracts or medical service plan contracts that provide pregnancy-related benefits. Patients need to meet the following conditions in order to get their IVF covered:
The patient's eggs must be fertilized with her spouse's sperm;
The patient or the patient's spouse must have at least a five-year history of infertility;
The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
The infertility must be associated with one or more of the following conditions:
Endometriosis;
Fetal exposure to diethylstilbestrol, also known as DES; Blocked or surgically removed fallopian tubes; or Abnormal male factors contributing to the infertility. (Hawaii Revised Statutes, Sections 431-1OA-116.5 and 432.1-604).
ILLINOIS: Illinois law requires insurance policies that cover more than 25 people and provide pregnancy-related benefits to cover costs of the diagnosis and treatment of infertility. The law defines infertility as the inability to get pregnant after one year of unprotected sex or the inability to carry a pregnancy to term.
Coverage includes, but is not limited to:
In vitro fertilization (IVF);
Uterine embry lavage;
Embryo transfer;
Artificial insemination;
Gamete intrafallopian transfer (GIFT);
Zygote intrafallopian transfer (ZIFT);
Intracytoplasmic Sperm Injection (ICSI);
Four completed egg retrievals per lifetime; and Low tubal egg transfer.
Coverage for IVF, GIFT and ZIFT is required only if:
The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy;
The patient has not reached the maximum number of allowed egg retrievals;
The procedures are performed at facilities that conform to standards set by the America Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.
Illinois law exempts religious organizations which believe the covered procedures violate their teachings and beliefs. (Illinois Compiled Statutes Annotated, Chapter 215, Sections 5/356m and 125/5-3).
MARYLAND: Maryland law requires health and hospital insurance policies issued or delivered in Maryland that provide pregnancy-related benefits to also cover the outpatient costs of in-vitro fertilization. HMO's must provide IVF benefits to the same extent as the benefits provided for other infertility services.
Patients need to meet the following conditions in order to get their IVF covered:
The patient's eggs must be fertilized with her spouse's sperm;
The patient is unable to get pregnant through less expensive covered treatments;
The IVF is performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.
The patient and his or her spouse must have at least a two-year history of infertility; OR their infertility must be associated with one or more of the following conditions:
Endometriosis;
Fetal exposure to diethylstilbestrol, also known as DES;
Blocked or surgically removed fallopian tubes; or
Abnormal male factors, including oligozoospermia.
Coverage may be limited to three in vitro fertilization attempts per live birth and a maximum lifetime benefit of $100,000.
A religious organization may, by request have this coverage excluded from its policies and contracts if the required coverage conflicts with its bona fide religious beliefs and practices.
Regulations that took effect in 1994 exempt businesses with 50 or fewer employees from having to provide the IVF coverage. (Maryland Insurance Article §15-810, Health General Article §19-706).
MASSACHUSETTS: Massachussettes law requires health maintenance organizations and insurance companies that cover pregnancy-related benefits to cover medically necessary expenses of infertility diagnosis and treatment. The law defines infertility as “the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period.”
Benefits covered include:
Artificial insemination;
In vitro fertilization;
Gamete Intrafallopian Transfer;
Sperm, egg and/or inseminated egg retrieval, to the extent that those costs are not covered by the donor's insurer;
Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility; and
Zygote Intrafallopian Transfer (ZIFT).
Insurers may, but are not required, to cover experimental procedures, surrogacy, reversal of voluntary sterilization or cryopreservation of eggs. (Annotated Laws of Massachusetts, Chapters 175, §47H; 176A, §8K; 176B, §4J; and 176G, §4, 211 CMR 37.00).
MONTANA: Montana law requires health maintenance organizations to cover infertility services as part of basic preventive health care services. The law does not define infertility or the scope of services covered; nor did the state ever draft regulations explaining what infertility services entail.
As for health insurers other than HMOs, the law specifically excludes infertility coverage from the required scope of health benefits those insurers must provide. (Montana Code Annotated, Sections 33-22-1521 and 33-31-102).
NEW JERSEY: New Jersey Family Building Act requires insurance policies that cover more than 50 people and provide pregnancy-related benefits to cover the cost of the diagnosis and treatment of infertility. The law defines infertility as the disease or condition that results in the inability to get pregnant after two years of unprotected sex (female partner under the age of 35) or one year of unprotected sex (female partner over the age of 35) or the inability to carry a pregnancy to term.
Coverage includes, but is not limited to:
Diagnosis & diagnostic tests
Medications
Surgery
In vitro fertilization (IVF)
Embryo transfer
Artificial insemination
Gamete intra fallopian transfer (GIFT)
Zygote intra fallopian transfer (ZIFT)
Intracytoplasmic Sperm Injection (ICSI)
Four completed egg retrievals per lifetime
Coverage for IVF, GIFT and ZIFT is required only if: The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy; The patient has not reached the maximum number of allowed egg retrievals and the patient is 45 years of age or younger.
The procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.
The law allows religious organizations to request an exclusion of this coverage if it is contrary to the religious employer's bona fide religious tenets. (New Jersey Permanent Statutes: 17B:27-46.1X Group Health Insurance Policies; 17:48A-7W Medical Service Corporations; 17:48-6X Hospital Service Corporations; 17:48 E-35.22 Health Service Corporations; 26:2 J-4.23 Health Maintenance Organizations)
NEW YORK: Insurers are required to cover the diagnosis and treatment of correctable medical conditions and shall not exclude coverage of a condition solely because the medical condition results in infertility. Private, group health insurance plans, issued or delivered in the state of New York providing coverage for hospital care or surgical and medical care are required to provide coverage for the diagnosis and treatment of infertility for patients between the ages of 21 and 44, who have been covered under the policy for at least 12 months. Certain procedures are excluded from this requirement, including IVF, GIFT, ZIFT, reversal of elective sterilization, sex change procedures, cloning, and experimental procedures. Plans that include coverage for prescription drugs must include coverage of drugs approved by FDA for use in diagnosis and treatment of infertility. (New York Consolidated Laws, Insurance, Section 3221(k)(6), Section 4303(s).)
OHIO: Ohio law requires health maintenance organizations to cover basic preventive health services, including infertility. The Ohio Insurance Department has no written definition of infertility services, but states that the procedure must be medically necessary. Experimental procedures are not covered. (Ohio Revised Code Annotated §1751) 1742 was repealed and replaced and the $2,000 General Interpretation no longer applies.
RHODE ISLAND: Rhode Island law requires insurers and HMO's that cover pregnancy services to cover the cost of medically necessary expenses of diagnosis and treatment of infertility. The law defines infertility as “the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year. The patient's co-payment cannot exceed 20 percent. (Rhode Island General Laws (§27-18-30, 27-19-23, 27-20-20 and 27-41-33).
TEXAS: Texas law requires certain insurers that cover pregnancy services to offer coverage for in vitro fertilization. That means insurers must let employers know this coverage is available. However, the law does not require those insurers to provide the coverage; nor does it force employers to include it in their health plans. Patients need to meet the following conditions in order to get their IVF covered:
The patient must be the policyholder or the spouse of the policyholder and be covered by the policy;
The patient's eggs must be fertilized with her spouse's sperm;
The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
The patient and her spouse must have at least a continuous five-year history of unexplained infertility, OR the infertility must be associated with one or more of the following conditions:
Endometriosis.
Fetal exposure to diethylstilbestrol (DES);
Blocked or surgical removal of one or both fallopian tubes; or Oligospermia.
Texas law does not require organizations that are affiliated with religious groups to cover treatment that conflicts with the organization's religious and ethical beliefs. (Texas Insurance Code, Article 3.51-6).
WEST VIRGINIA: West Virginia law requires health maintenance organizations to cover basic health care services, including infertility services, when medically necessary. The West Virginia Insurance Commissioner does not define infertility services. (West Virginia Code §33-25A-2).
TABLE 6STATE INFERTILITY COVERAGE AT A GLANCE(OCTOBER 2005)IncludesExcludesIVFMandateMandateIVFIVFcoverageStateDate enactedto coverto offercoveragecoverageONLYArkansas1987X1XCalifornia1989XX2Connecticut1989XXHawaii1987XX3Illinois1991XX4Maryland1985X5XMassachusetts1987XXMontana1987X6New Jersey2001XXNew York1990X7Ohio1991X8Rhode Island1989XXTexas1987XXWest Virginia1977X81Includes a lifetime maximum benefit of not less than $15,000.2Excludes IVF, but covers gamete intrafallopian transfer (GIFT).3Provides a one-time only benefit covering all outpatient expenses arising from IVF.4Limits first-time attempts to four oocyte retrievals. If a child is born, two complete oocyte retrievals for a second birth are covered. Businesses with 25 or fewer employees are exempt from having to provide the coverage specified by the law.5Businesses with 50 or fewer employees do not have to provide coverage specified by law.6Applies to HMOs only; other insurers specifically are exempt from having to provide the coverage.7Provides coverage for the diagnosis and treatment of correctable medical conditions. Does not consider IVF a corrective treatment.8Applies to HMOs only.
It is evident from the above that of the fourteen states which require insurers to either cover, or offer to cover some form of infertility diagnosis and treatment, provide, for the most part limited and deficient benefits that will be exhausted in a short time, often with many restrictions and conditions attached. At the national level, in states other than the fourteen states mentioned above, the majority of medical insurance plans don't cover infertility benefits at all. In today's difficult environment, where tough choices must be made by medical insurers to provide maximum health benefits at a minimum cost, it is expected that even the limited and deficient infertility benefits available today will be further reduced and curtailed.
In 2002, one percent of the babies born in the United States were conceived, based on assisted reproductive technology treatments. Some insurance companies currently assist in initial fertility evaluations of couples seeking to have children; these evaluations include: semen analysis, documentation of competent ovulation and documentation of tubal patency; however, such evaluations are costly. In addition, the costs associated with infertility treatments are very expensive. Few insurance companies provide insurance coverage and/or assistance for couples who contract with or who intend to contract with medical providers who perform the specialized medical procedures comprising infertility treatments either in the United States or outside of the jurisdiction of the United States. Currently, people who do not have coverage for infertility treatments will need to apply for loans with very high interest rates, or take out home equity loans to obtain funds to pay for infertility treatments. Not only is the high cost of treating infertility prohibitive, but also the prohibitive nature of the costs generate significant stress for couples seeking infertility treatments; and this stress can cause relationships of some frustrated couples to end in separation and/or divorce. There are no known comprehensive financial services and/or products that support or provide insurance coverage for all of the potentially required fertility diagnoses and infertility treatments and options.
Therefore, the need exists for the provision of comprehensive methods and systems for providing and paying for insurance coverage of treatable infertility conditions that affect at least 7.3 million women and their partners (12% of the reproductive age population) in the United States.
Furthermore, the need exists for the provision of affordable payment options and payment plans for insurance coverage of treatable infertility conditions. In addition, the need exists for computer implemented, automated business methods and systems of providing insurance coverage of treatable infertility conditions, so as to reduce emotional and financial stress for patients, health care providers and insurance providers, interested in the delivery of infertility treatments and services. Thus, the focus of this invention is to provide insurance coverage for infertility treatments for individuals in a disciplined manner, enabling individuals to set aside money to address future issues that may interfere with them or their children or grandchildren giving birth to offspring. An additional focus of this invention is to assure that the best available technology is employed to provide a wide comprehensive spectrum of innovative fertility treatments and options to those seeking childbirth. Ultimately, the invention provides leadership in the field of providing financial products for fertility treatments in reproductive medicine, including male and female infertility treatments and to advance knowledge and technology in the science and practice of reproductive medicine.
Additionally, there can be a plurality of income streams associated with various incentives, bonuses and options, in regard to insurance coverage for infertility treatment. This invention can be used by any number of insurance carries and underwriters on a for fee basis. The insurance carriers and/or underwriters can provide incentives to other insurers and underwriters, in order to promote the income generation capabilities of a comprehensive fertility insurance program in various jurisdictions throughout the United States. However, the main income associated with the fertility insurance program will be from the premiums paid by the purchasers of the comprehensive fertility insurance policies.